After daily new COVID-19 cases peaked on September 16, 2020, during the first wave, new cases and deaths in India began to increase from the third week of February 2021, marking the beginning of the second wave. The rise in daily cases and deaths has been steep since April 1. On April 14, India reported nearly 2 lakh cases. The seven-day average test positivity rate has also been climbing. What will it take to contain the second wave? In a conversation moderated by R. Prasad , Gautam Menon and Giridhara Babu discuss some possible options. Edited excerpts:
When do you think the second wave is likely to peak? And when we see such a peak, what do you think will be the number of daily cases?
Gautam Menon: That is very hard to say as you have to know what is the significance of reinfection, what is the level of immune escape that is happening. It’s clear that these new variants are spreading much faster and the reproductive ratio is significantly higher than the reproductive ratio in earlier cases. So far, there seems to be no sign of any point of inflection in the data. So, my guess is that it is going to get a lot worse before it gets better. We may be seeing around 2.5 lakh new cases per day. These are just guesses. The peak will be at the end of this month to the first week of next month.
There have been very few restrictions in the movement of people within and across States. Should we restrict such movement to contain the spread?
Gautam Menon: We will probably have to curb inter-State travel at this point. But we can only make that decision when we know how much these new variants have spread. I think the rising cases everywhere are driven by the new variants. If they have already spread sufficiently, restricting inter-State travel would be pointless now. So, we need data. Apart from that we need to worry about closed spaces; masking; the intensity of religious and political events, which we need to maybe forbid altogether. I think we will have to restrict the movement of people both within and across States.
Giridhara Babu: I think it’s a bit late. In the first to second week of February, we saw the reproductive number going up and we knew where the localised outbreaks were. That was the time we should have done concurrent genomic sequencing with epidemiological investigations. Even the results of the genomic sequencing were made available in the third week of March. So that won’t be useful in containing the transmission to a limited area.
I believe that there are many variants in circulation. It’s a pity that we are guessing that this variant might be there and so let’s restrict people from going from one State to another. This panic is not justified by data. The easiest thing to do right now is strictly enforce containment measures. If you fail there, especially in reducing the overall transmission trajectory in some of the places that have been hit the hardest, we will lose this opportunity also. It’s a bit late to restrict inter-State travel.
If it’s a new variant that is possibly responsible for the second wave, why do we see more cases in certain States and not in every State?
Gautam Menon: We are not doing enough genomic surveillance. Even now we don’t know how much Maharashtra has changed between March 24 and today. We know that this variant in Maharashtra has quickly spread to at least 10 States or so. But how those numbers have changed and how much of the spike is in response to that variant we don’t know.
What do you think are the reasons for States that went to the polls not seeing a surge compared to Maharashtra?
Giridhara Babu: If there is a newer variant in circulation, every State is at risk. Some are at higher risk than others depending on when the variant entered the State. Inefficient testing, especially an inefficient syndromic approach, and review and monitoring of COVID-19 responses getting second priority over elections are definitely the reasons why we might have missed it.
Gautam Menon: In general, an outdoor activity carries less risk than an indoor one.
On March 24, 2020 we went into lockdown when the number of cases was less than 5,000. But now, when there are close to 2 lakh cases a day, we are seeing no restrictions even in closed spaces such as restaurants, theatres and gyms. Are we doing the right thing by allowing such businesses to operate?
Gautam Menon: If there is a closed, badly ventilated surrounding, you should not allow people to gather there. But what we have not done is to encourage people to go outdoors. All our messaging has been negative so far — do not do this, do not do that. Psychologically this is a mistake. Because unless people understand or have a sort of framework of behaviour in which they can operate, it becomes hard for them to make decisions, and then they will finally throw caution to the winds. Experts from different fields have to discuss this and see if we can alter the messaging a little. You do need to give people some outlet somewhere and I think this has not been sufficiently discussed, and it needs to be done.
Giridhara Babu: These decisions are made based on how much power and influence these sectors have. For example, in Karnataka, there was a rule to allow only 50% attendance in theatres. Due to pressure, there was an immediate reversal of the rule and 100% attendance was allowed for a week. Taking a cue from this, people from other sectors also got relief. Now, if there is competition of sorts of how much relaxation each sector gets, this is not the way we can win over this virus. We’re giving more reasons for the virus to flourish. And then we say, we don’t want a lockdown.
Are we carrying out contact tracing and isolating those people who have been found positive in institutional facilities?
Giridhara Babu: There are too many generals and few soldiers. No additional manpower has been granted; we have not used the opportunity to step up preparedness but we want the same people to be tackling the second wave, which is more infectious. We need to have a complete relook at the way health manpower is managed in this country.
Gautam Menon: When there is large-scale community transmission, contact tracing becomes a bit irrelevant. The question is whether we should even divert resources to that.
Are States really prepared to handle the potentially huge inflow of patients to hospitals?
Giridhara Babu: There are inter-regional and intra-regional disparities in health system access and delivery. If you look at Maharashtra, the distribution of hospitals and healthcare workers in Mumbai is different compared to other districts. That’s why those districts face a greater strain on their health system compared to Mumbai. In Uttar Pradesh and Bihar, there is a very poor distribution of health system capacity both in terms of infrastructure and human resources. The worry is that with the reproduction number [R0] almost nearing three, these two States will probably have the highest number of cases. Even if you assume 5% of these people need hospitalisation, we have no beds in those States or in the nearby States. And this is what we need to prevent. We need to be very strategic in helping the States with poor resources.
More than 100 million doses have been administered in India. But we have vaccinated just about 6.5% of the population. What can be done to increase vaccine uptake? Is there vaccine hesitancy?
Gautam Menon: Vaccine hesitancy has now decreased. There are genuine vaccine shortages in multiple States which have seen a huge uptick in cases. There are many questions whether Serum Institute of India will be able to provide the number that it had promised earlier and how these will be divided between Indian and non-Indian recipients.
Giridhara Babu: Vaccine hesitancy is the least of our problems. We have a complicated list of problems including lack of micro planning, lack of mobilisation, lack of better communication, and lack of a vaccination policy on how to go about vaccination in different phases. Most importantly, in every vaccination campaign, we have had a separate plan for social mobilisation of the minorities. We don’t have that yet for COVID-19. So, it’s incomplete preparation.
The private sector has claimed that if allowed, it will exponentially increase the number of vaccines given each day. But it hardly holds 10% of the sessions across India now. What is the reason for this and how can this be scaled up?
Giridhara Babu: For nearly four or five decades now, it is the public health sector which has been the main player in vaccination programmes. So, if we are expecting the private health system to outsmart the public health system in coverage of vaccines just for COVID-19, that’s a wrong assumption. The private health system has a definite and clearly identified population that it caters to, but even that is changing both in terms of COVID-19 care and vaccination. There are government health facilities that are saying that for the first time they are seeing rich people coming to them. The kind of cold chain system in the government system is far superior. But if there are more vaccines, and people want to pay for these vaccines, then the public health system cannot get to it. That’s where the strength of the private health system is. I think we need to recognise the trends of each system and see which is the target population for those systems, and work out mechanisms around it.
Serum Institute and Bharat Biotech are about to scale up production to meet the demand. Do you think it’s time that the government provides them financial support?
Gautam Menon: Absolutely. This is a time where we and every other country in the world needs vaccines in large numbers. Government intervention and support can make a huge difference in the long term.
Do you think the vaccine shortage will be eased now that Dr. Reddy’s lab can import Sputnik V?
Giridhara Babu: The shortfall in supply will be reduced to some extent. But I am not confident whether it will completely take care of the demand in terms of covering the eligible population above 45 years. I would imagine that at least 10 million doses are necessary per day to completely vaccinate 30% of the population in the next two months.
Gautam Menon: It’s also important to have a broad base of multiple vaccines, because we don’t know the answers to questions like which vaccine might be better against which variant. This may alter our policy in terms of where to send which vaccine at what time. In general, it will improve the availability of vaccines overall, and will strengthen our ability to at least meet the target of 300 million to be vaccinated by August, which is an important target.
Giridhara Babu is an epidemiologist at the Public Health Foundation of India and a member of the Karnataka COVID-19 Technical Advisory Committee; Gautam Menon is a Professor of Physics and Biology at Ashoka University
